Pediatric and adult clinicians, along with family physicians and community partners, should work together to better streamline the transition from pediatric to adult care for young people with medical needs, says a new position statement from the Canadian Pediatric Society complex.
To help patients, physicians particularly need system strategies, including specialized education on transitional care issues and referral recommendations based on each patient’s stage of development.
“There is a serious lack of integration of care across various sectors – particularly primary and tertiary or specialist care – and this negatively impacts the engagement of young people and potentially jeopardizes their health outcomes as young adults,” lead author Alene Toulany, MD, an adolescent medicine specialist at the Hospital for Sick Children and assistant professor at the University of Toronto, Canada, said. Medscape Medical News.
“We need to break down these barriers to improve the quality of care and transition experience for young people and their families,” she said.
The position statement was published online April 13.
Four proposed steps
In Canada, provincial and territorial funders require young people to transition from pediatric to adult care between the ages of 16 and 19. The current configuration of pediatric and adult services often leads to piecemeal care, which can create barriers to continuity of care, especially for young adults with complex physical, developmental or mental health issues.
Toulany, in collaboration with the Canadian Pediatric Society’s Committee on Adolescent Health, wrote the position statement to draw attention to a more systems-based approach to improving care. Committee members include Jan Gorter, MD, PhD, professor of pediatrics at McMaster University in Hamilton, Ont; and Megan Harrison, MD, associate professor of pediatrics at the University of Ottawa in Ontario.
“Despite our extensive knowledge of the challenges associated with transitioning to adult care, we have not made significant progress in improving outcomes for young people over the past 20 years,” Toulany said.
In the position statement, the authors outlined four essential steps to a successful transition, emphasizing that each component should be youth-centred, strengths-based, and developmentally appropriate.
As a first step, providers should begin transition planning early by regularly assessing transition readiness with patients and their caregivers. Physicians need to understand each young adult’s potential and goals for activity, education, recreation, and vocation.
In the second step, providers should create an individual transition plan and identify a transition “champion” or clinician who coordinates the various providers and solicits input from the patient and their caregivers, filling in gaps in preparedness, the autonomy and confidence of young people if necessary. .
In the third stage, physicians should provide pre-transition support by offering education and peer support to patients and their caregivers. This phase could include a phased approach to increasing independence in managing care and a comprehensive summary of health transfer based on family priorities.
In the fourth stage, physicians should provide ongoing support after the transition by ensuring patients show up for appointments and monitoring their attachment to adult services. This could continue to include caregivers based on patient preference, with tapering over time.
The overarching goals are to increase the young patient’s level of responsibility in their own health care management, strengthen their understanding of their chronic health conditions, and develop their skills to navigate the complex adult health care system. .
“As a clinician-scientist, I have seen firsthand how young people with chronic conditions and their families often struggle and feel alone,” Gorter said. Medscape Medical News.
“Only together can we learn from each other and can develop realistic solutions and healthcare interventions that will have a direct impact on patients, their families and those working in the healthcare system. health,” he said.
Avoid bad results
Transitioning young people with complex health care needs involves more than the medical transfer itself, the authors write. Patients, their caregivers and multiple physicians should be included. Without proper transition, poor health outcomes often occur once young adults move on to adult services.
For example, in a study conducted in Ontario, the rate of diabetes-related hospitalizations increased significantly over the 2 years following transfer to adult care, the authors wrote. In another study, nearly half of Ontario youth had a gap of more than 12 months in their diabetes care when transitioning to adult care. Other studies in Canada have found complications in young cystic fibrosis, congenital heart diseaseand organ transplants.
Additionally, adolescence and early adulthood bring other major physical, psychosocial, and developmental changes, which can further affect health outcomes. During this time, young people need support to develop self-management skills, navigate new relationships and adapt to changes in education, career, housing and personal circumstances, the authors write. With all these changes, young adults may not place the same importance on health as other transitional areas of their lives.
“Combined with other life transitions occurring at the same time as the health care transition, this is a difficult stage of life,” said congenital heart disease specialist Andrew Mackie, MD. at Stollery Children’s Hospital and Professor of Pediatrics at the University of Alberta. Edmonton, says Medscape Medical News. He did not participate in the drafting of the position statement.
“What a missed opportunity it would be for medical professionals to have invested so many resources in saving lives in childhood, only to then drop adolescents and young adults as they age out of pediatric care,” did he declare.
Adapt the transition
Transition interventions must be carefully tailored, timed, and integrated into the broader health system, the authors write. Limited evidence supports any particular intervention due to the complex nature of chronic health conditions, as well as physical and mental comorbidities. This means that flexibility in transitional care is essential, they write.
More flexible age thresholds, rather than a chronological age requirement, may better reflect developmental age and readiness for transition, the authors write. According to this model, young people would receive increasing levels of information and responsibility as they move through the developmental stages of adolescence at their own pace. Program funding and payment models could support seamless, shared, and integrated care between pediatric and adult health services.
Health system leaders should also recognize specific high-risk groups to ensure equitable access to health services. Children with complex health care needs who live in rural or remote settings, for example, may need greater transitional support, as well as those who face economic, educational or cultural marginalization .
Primary care teams and community services should be involved in a “holistic approach” during the transition, say the authors, and integrate the social determinants of health – such as housing, school, employment and social services – to meet the needs of young people “where they live.”
“The transition to adulthood can be overwhelming, and we all know how hard it is to change your practice,” Gorter said. “It starts with taking action. Everyone can do something, and the little things can make a big difference.”
The position statement has been reviewed by the Bioethics, Community Paediatrics, and Mental Health and Developmental Disabilities Committees of the Canadian Pediatric Society (CPS), as well as the Executive Committee of the CPS Hospital Paediatrics Section. . It has also been reviewed by the Chairs of Pediatrics of Canada and members of the College of Family Physicians of Canada, Advisory Committee on Family Medicine, and has been reviewed and approved by Children’s Health Canada . Toulany, Gorter and Mackie did not disclose any relevant financial information.
Canadian Pediatric Society. Published online April 13, 2022. Full Text